R. Di Sciacca

Twenty-four hour ambulatory blood pressure monitoring to evaluate effects on blood pressure of physical activity in hypertensive patients.

ObjectiveElevated blood pressure is an important risk factor for cardiovascular disease and stroke. Several studies have demonstrated that physical exercise reduces blood pressure levels in hypertensive subjects and improves control of several well-known risk factors for atherosclerosis such as diabetes mellitus, blood lipid profile and obesity. Our group attempted to evaluate if an exercise program based on periodic controlled fast walking sessions would reduce blood pressure levels in hypertensive subjects. DesignWe enrolled hypertensive subjects not suffering from obesity (Body Mass Index <30) already under pharmacological therapy; in these subjects we performed a six-week program of mobility exercise based on fast walking. SettingSecondary care. PatientsWe enrolled 189 subjects; 168 subjects completed the training period. Entry criteria were Stage I WHO hypertension in pharmacological treatment, BMI <30, and absence of any pathological condition resulting in reduced mobility. InterventionsA six-week mobility program centered on fast walking. Main Outcome MeasurementsSystolic and diastolic blood pressure levels before and after the walking program. ResultsMean 24 h systolic blood pressure changed from 143.1 to 135.5 mmHg. Mean 24 h diastolic blood pressure changed from 91.1 to 84.8 mmHg. ConclusionsThis reduction, evaluated with Ambulatory Blood Pressure Monitoring (ABPM), confirms that physical exercise should be a part of lifestyle changes for the management of hypertension both in untreated hypertensive patients or high-risk subjects for hypertension, and also for hypertensive patients in association with pharmacological therapy.

Fetuin-A and CD40 L plasma levels in acute ischemic stroke: Differences in relation to TOAST subtype and correlation with clinical and laboratory variables

INTRODUCTION Accumulating evidence suggests that inflammation plays an important role in the acute phase of ischemic stroke. CD40 L is a well recognized atherosclerotic inflammatory marker, whereas recent evidence suggests a pro-inflammatory role of Fetuin-A. To analyze the role of an inflammatory marker such as CD40 L and of a candidate pro-inflammatory marker such as Fetuin-A in acute stroke we evaluated their serum levels in subjects with acute ischemic stroke and their possible association with other laboratory and clinical variables. MATERIALS AND METHODS We enrolled 107 consecutive patients with a diagnosis of acute ischemic stroke admitted to the Internal Medicine Department at the University of Palermo between November 2006 and January 2008, and 102 hospitalized control patients without a diagnosis of acute ischemic stroke. RESULTS Patients with acute ischemic stroke in comparison to control subjects without acute ischemic stroke had significantly higher CD40 L levels and Fetuin-A serum levels. No significant differences in plasma CD40 L or Fetuin-A levels among different TOAST groups were detected. At intragroup (intra-TOAST-subtype) correlation analysis, among subjects classified as lacunar, CD40 L plasma levels were positively correlated with LDL-cholesterol and with diabetes, whereas Fetuin-A was significantly (positively) correlated with hypertension and white blood cell count. Among subjects with LAAS subtype, CD40 L levels were positively correlated with triglyceride plasma levels and Fetuin-A, whereas Fetuin-A levels were positively correlated with LDL-cholesterol. DISCUSSION Our findings suggest a pro-inflammatory role of Fetuin-A and CD40 L in acute stroke setting. Whether this role should be construed as direct or as a simple expression of a general inflammatory activation will be up to future studies to clarify.

Changes in natriuretic peptide and cytokine plasma levels in patients with heart failure, after treatment with high dose of furosemide plus hypertonic saline solution (HSS) and after a saline loading

BACKGROUND AND AIMS Neurohormonal activation and inflammation characterizes heart failure, relates to outcome, and is a therapeutic target. The aim of this study was to evaluate the effects of high-dose furosemide plus small-volume hypertonic saline solutions (HSS) on natriuretic peptides and immuno-inflammatory marker levels and to analyze, after treatment, the response to acute saline loading. METHODS AND RESULTS 120 patients with heart failure treated with high-dose furosemide+HSS (Furosemide/HSS group) were matched with: 30 subjects with heart failure treated with high-dose furosemide (furosemide group), 30 controls with asymptomatic left-ventricular dysfunction (ALVD) (asymptomatic group) and 30 controls without heart failure or ALVD (Healthy group). We evaluated plasma levels of natriuretic peptides and cytokine levels in baseline, after treatment and after acute saline load. After treatment with high-dose furosemide+HSS compared to treatment with furosemide alone we observed a significant lowering of ANP [96 (46.5-159.5) pg/ml vs 64 (21-150) pg/ml], BNP [215.5 (80.5-487) pg/ml vs 87 (66-141.5) pg/ml], TNF-α [389.5 (265-615.5) pg/ml vs 231.5 (156-373.5) pg/ml], IL-1β [8 (7-9) pg/ml vs 4 (3-7) pg/ml], IL-6 [5 (3-7.5) pg/ml vs 3 (2-4) pg/ml], plasma values and after an acute saline load, a lower percentage change of ANP (+18.6% vs +28.03% vs +25% vs +29%), BNP (+14.5% vs +29.2% vs +30% vs +29.6%) TNF-α (+10.8% vs +15.8% vs +17.8% vs +11.3%), IL-1β (+20% vs 34.4% vs 40% vs 34.4%) compared to control groups. CONCLUSIONS Treatment with HSS could be responsible for a stretching relief that could influence natriuretic and immuno-inflammatory markers.

Clinical Trial: High‐dose furosemide plus small‐volume hypertonic saline solutions vs. repeated paracentesis as treatment of refractory ascites

Background  In patients with cirrhosis, ascites is defined as refractory when it cannot be mobilized or recurs early in standard diuretic therapy.

Effects of clinical and laboratory variables at admission and of in-hospital treatment with cardiovascular drugs on short term prognosis of ischemic stroke. The GIFA study

INTRODUCTION No information exists, to our knowledge, about the possible role of cardiovascular drug administration in the acute phase of ischemic stroke and possible effects on stroke outcome. The aim of our study was to evaluate the relationship between in-hospital treatment with cardiovascular drugs in patients with acute ischemic stroke and some outcome indicators. METHODS AND RESULTS 1096 subjects enrolled in the GIFA study, who had a main discharge diagnosis of ischemic stroke represent the final sample. Drugs considered for the analysis were the following: ACE-inhibitors (ACEI), angiotensin II receptor blockers (ARBs), statins, calcium-channel-blockers (CCBs), antiplatelet (APL) drugs, antivitamin-k (VKAs), and heparins. As outcome indicators we choose in-hospital mortality, cognitive function evaluated by Hodkinson Abbreviated Mental Test (HAMT), and functional status evaluated by activity daily living (ADL). Indicators of a good outcome were: no in-hospital mortality, HAMT >6 and 0 ADL impaired. Patients with a good outcome showed a higher rate of in-hospital treatment with ACE-inhibitors, calcium-channel blockers and a lower rate of pre-treatment with heparin. CONCLUSIONS Our study suggests that if a patient with acute ischemic stroke has higher SBP at admission, higher total cholesterol plasma levels, a lower Charlson index and is treated with ACE-inhibitors, calcium channel blockers and antiplatelet drugs, the short term outcome is better in terms of in-hospital mortality and functional indicators such as cognitive and functional performance at discharge.

39 POLYMORPHISM OF PROINFLAMMATORY AND ANTI-INFLAMMATORY GENES IN PATIENTS WITH ACUTE ISCHEMIC STROKE

Backgrounds: the improvement in heart surgery and anaesthesiology techniques in last decades have improved morbility and mortality ratio also in high surgical risk patients. Enteral ischemia after heart surgery is a rare complication (0.2 2%), but carries significant mortality (70 100%): its incidence has not been changed in these years and cases reported in literature are even increased. Pathogenesis has not been clearly understood, being complex and multifactorial: the principal cause seems to be the reduction in cardiac outflow during operation. Splancnic atherosclerosis could be also implicated in worsening or favouring enteral ischemia. Actually no relevant articles have been yet published concerning splancnic vessels screening before heart surgery. Atherosclerosis extension is only assessed with carotid duplex ultrasound and anamnestic data about previous cardiovascular events. Scope: aims of the study were to evaluate duplex scanning utility and accuracy to identify atherosclerotic lesions in splancnic vessels and to relate them with other arterial districts involvement. Methods: we studied 91 patients previously subjected to coronary angiography before heart surgery (coronary by-pass, valvular prothesis or both) at “Centro Gallucci” of “Azienda Ospedaliera di Padova”. They were all investigated with echocolordoppler of carotid arteries, aorta and its principal branches, and lower limbs arteries: if some haemodinamic stenosis were found a second level (Angio-CT or Angio-NMR) exam was performed to confirm the previous one. Chi-square test was employed in statistical analysis comparing atherosclerotic lesions distribution. Results: prevalence of carotid lesions and peripheral arterial disease was major among patients with at least one coronary artery critical stenosis; this data was not related with the number of vessels involved. Superior mesenteric artery (SMA) plaques were four times more frequent in patients with critical coronaropaty: no patients without critical lesions in coronary arteries had a >70% SMA stenosis. Carotid plaques (>1.5mm thickness), in particular those >50%, were more frequently associated with critical lesions at coronary angiography, even more than intima-medial thickening (95% vs 45%). Among patients with any degree peripheral arterial disease (PAD), 72% had coronary critical stenosis versus 30% in patients without PAD; if haemodinamic stenosis were found in lower limb arteries the prevalence of coronary critical plaques were 95%. Patients with any carotid plaque had a 44% prevalence of SMA stenosis (whatever degree), while in patients without carotid lesions it was 12.5%. No one with unaffected lower limb arterial wall had atherosclerotic SMA involvement, while if PAD was present, there was a 40% prevalence of SMA plaques (any degree). From this study also stand out that in patients with carotid stenosis >50%, and mainly among those with PAD, splancnic vessels were involved more frequently then in people without them. Both carotid plaques and PAD had a 100% sensitivity to predict a critical stenosis at SMA, even if specificity was below 50%. Conclusions: abdominal vessels duplex scanning is indicated before heart surgery only when atherosclerotic plaques are found in carotid and lower limbs arteries. Finding that kind ok lesions in pre-surgery evaluation should suggest the operator to put to use all devices useful for preventing vascular complications in the splancnic district. Echocolordoppler, if performed by an export operator, could be useful to detect the presence of atherosclerotic plaques or abdominal aortic aneurisms in abdominal vessels.